I have already had the opportunity to work with Vitreq’s forceps, which have improved my surgeries, because of the broader instrument tip and more rigid design.

Peter Stalmans is one of Europe’s leading retina specialists. He currently works as a vitreoretinal surgeon at the Ophthalmology Department of the University Hospitals Leuven. Alongside running his clinical practice in Leuven, Belgium, Peter is extensively active in clinical and experimental research in ophthalmology and has wide ranging knowledge of ophthalmological techniques, systems and instrumentation. He is a member of the American Academy of Ophthalmology (AAO), the American Society of Retina Specialists (ASRS), the European Society of Retina Specialists (EURETINA), the European Vitreoretinal Society (EVRS), European Vision & Eye Research (EVER), and a Board Member of the Belgian Ophthalmology Society (BOG). He has authored more than 100 international scientific publications, and is frequently invited as a guest speaker at various congresses worldwide. He has also organized several international symposiums and congresses on developments in treatment of retinal diseases, and regularly broadcasts live surgeries to medical centers and congresses worldwide.

Which instrument do you most value and which features make this instrument so effective?

Apart from the disposables we use for the vitrectomy device, my ‘most used’ intraocular instrument is the end-gripping forceps. There are different styles of end-gripping forceps: with round edges; square edges; symmetrical- and asymmetrical forceps, however, I use end-gripping forceps for 99% of my work, as due to the round edges of these forceps, I can minimize trauma. If you use forceps with square edges, the little edges tend to pinch a little too hard in the retina and can cause hemorrhages. I also prefer symmetrical forceps over asymmetrical forceps, as you will always have the same area of contact with the retina, regardless of the angle of approach. End-gripping forceps are produced by different manufacturers, but there is a difference in quality. What matters for me with respect to quality, firstly is the rigidity of the forceps. As we are switching more and more to very small gauge instrumentation, it becomes an increasingly important issue. For example, the forceps from Vitreq that I have been using have made a huge difference, compared to the forceps that I usually use. The forceps are not completely bent when extracted from the eye, and are reusable, so the lifespan will be much higher compared to other types. Another second feature that I find important in forceps is the surface of the tip. The broader the tip is, the more easily you can grasp the membrane, because there is more contact surface between tip of the forceps and the membrane. I was surprised how broad the 27 Gauge forceps that I received from Vitreq are, and I was really amazed that you could introduce the instrument through a 27 Gauge cannula. It’s very nicely done. The third thing that I find important is that it is not too reflective. When you are using a high power LED light in the eye, it is important that you don’t have too many reflections from the forceps. Vitreq’s forceps have a slightly opaque finish, which is quite nice to use.

Which instrument or procedure currently proves the most challenging to you in your daily practice? And what could be improved?

Scissors can provide challenges. Firstly, I don’t believe in using reusable scissors, because when you re-sterilize them, they become blunt, so I always work with disposable scissors. When you want to cut something from the retina, like the neovascular membrane or a proliferative vessel, you want the tip of your instruments to be parallel to the retina, and because you always approach at a certain angle, bent instruments are preferable. Of course, the smaller the gauge is, the harder it is to make curved instruments. The curvature should be as high as possible, within the limits of being able to introduce into a cannula. Secondly, the scissors must be sharp, by definition, but the sharpness needs to extend all the way to the tip. The tip needs to fully close, so when you cut something you are sure that you are cutting effectively. If the scissors are a little open at the tip, it is difficult to judge how deep you are cutting. Also, of course, a matt finish and rigidity are important. Another key thing is pricing.

What experience have you had of working directly with companies to develop new instruments and/or surgical techniques? What are the benefits and/or limitations of working directly with companies?

Sometimes you notice that each time when you use a certain instrument, the same issues arise, and you say to yourself: “If the instrument worked a little bit like this or that, it’s effectiveness could be improved.” The interesting thing is that if you can communicate that directly to the R&D department of a company and they are willing to take your comments into account, you can really improve instruments. What’s important is to speak directly to the people involved in designing the instrument. If you share your ideas with a sales representative, you might be lucky that the information reaches the R&D department and then even luckier if they do something with it. In most companies, the only guys you see are the sales representatives.

What do you expect to see developing in the future (e.g. the next 3-5 years) in VR surgery?

I have noticed that there is an increasing move towards 27 Gauge surgeries. If you had asked me six months ago, I would have told you that I don’t believe I would ever do more than 10% of my surgeries in 27 Gauge, but with the advent of better vitrectomy systems with better flow, I have now switched almost completely to 27 Gauge. I am doing over 80% of my cases in 27 Gauge. However, then, of course, you bounce into new limitations and that’s currently mainly illumination. We do now have more powerful light sources, with LED lights and everything, but now the light must pass through a 27 Gauge opening, and that has become a real limitation now. If you want to have proper illumination in the eye, you must introduce a chandelier into the eye. It would be better if we could have, for example, more transparent light bulbs or more powerful light sources or a combination of both for better illumination. While instrumentation has really advanced, illumination still holds us back.

What are your own priority focus areas for the next few years- either in research or clinical practice?

I am currently working on a robotic system that holds the instruments for you in the eye, because, for example, when you have an occluded vessel in the eye, if you could introduce a fine needle into the vessel and dissolve the vessel, you can cure the disease. The problem is that firstly, no needles that are fine enough for that are currently available. And secondly, and more difficultly, is that you would need to hold and extremely fine instrument in the eye for several minutes and you cannot do that by hand. This project is about a robot that can hold a needle for you into the eye. So you introduce the unit yourself. The needle is connected to a robot arm and once you have introduced it, you can just release it and it will hold the needle. We are working on the first application of the robot and hope to do the first clinical experiments with this device in early 2016.

Do you think that Vitreq instrumentation will be valuable in your own work in the future?

Yes. I have already had the opportunity to work with Vitreq’s forceps, which have improved my surgeries, because of the better, more rigid design.

What do you envisage Vitreq’s role in the market to be?

I definitely think that Vitreq will play a role in developing next generation instruments for the VR society.